CHARAKTERYSTYKA KLINICZNA I LABORATORYJNA WIRUSOWEGO ZAPALENIA WĄTROBY TYPU D W REPUBLICE SACHA (JAKUCJA)

Vadim G. Krivoshapkin1, Sergei I. Semenov1, Svetlana S. Maximova1, Nadegda N. Tihonova2, Anna I. Sivtseva1, Snegana S. Sleptsova1

1 M.K. Ammosov North-Eastern Federal University, Yakutsk, Russia

2 Yakutsk City Clinical Hospital, Department of Viral Hepatitis , Yakutsk, Russia

ABSTRACT

Inrtroduction: The epidemiological situation for hepatitis D has changed significantly. Reduced population authors infection due to a sharp decline in hospitalizations from Central Asia regions, the Caucasus and Moldova, which are known to be endemic for hepatitis D. Currently, the incidence of chronic hepatitis D (HGD) in Russia is 1%, while in the countries of Central Asia, and in particular in Turkmenistan, the share of HGD among chronic viral hepatitis is 8%.

The aim of research was to establish the clinical features, depending on the activity of the replication of hepatitis viruses B and D.

Materials and Methods: We studied 26 patients with viral hepatitis D with a determined activity replicative virus by PCR (polymerase chain reaction). The age of patients ranged from 28 to 78 years. The patients performed the ELISA (enzyme-linked immunosorbent assay) study for the presence of markers of parenteral viral hepatitis (HBsAg, a-HCV and a-HDV), the standard general clinical biochemical blood tests. of the instrumental methods survey used ultrasonography (ultrasound), EGD (fibrogastroduodenoscopy). Grading the severity of liver cirrhosis established by Child-Pugh (eng. Child-Pugh, Child-Turcotte, Child-Turcotte-Pugh, sometimes Child-Paquet) is designed to assess the severity of cirrhosis. The severity of liver cirrhosis is assessed on a point system, which are calculated from 5 or 6 parameters.

Results: It is established that most HGD more prevalent among young people bodied (69%) and occurs mainly in severe symptoms and portal hypertension leading to the rapid development of liver cirrhosis (53%). It showed that hyperenzymemia reaches high levels of ALT to 1715 U / L. with a high viral DNA load virus (HBV) 2648226,0 ± 953892,7 copies / ml in the presence of an RNA virus D (HDV +).

Conclusion: Thus, the main feature of chronic hepatitis D is its predominant tsirrogennost.

Wiad Lek 2018, 71, 1 cz. II, -183

Introduction

Chronic delta infection (the HDV infection) is one of the most severe and rapidly progressing liver disease with a high risk of developing cirrhosis and hepatocellular carcinoma (HCC). HBV markers D (HDV-infection) can be infected up to 5% of the patients with HBV-infection and, thus, it is believed that there are approximately 15-20 million patients with chronic hepatitis D [1,2]. The epidemiological situation for hepatitis D has changed significantly. Reduced population authors infection due to a sharp decline in hospitalizations from Central Asia regions, the Caucasus and Moldova, which are known to be endemic for hepatitis D [3]. Currently, the incidence of chronic hepatitis D (HGD) in Russia is 1%, while in the countries of Central Asia, and in particular in Turkmenistan, the share of HGD among chronic viral hepatitis is 8% [4]. According to our research we recorded a high prevalence of the HDV-infection in the Republic of Sakha (Yakutia) and its individual medical and geographical areas: in Viluskii and arctic regions of antibody to hepatitis D (a-HDV) was determined in 14% and 9.9%, respectively, while the average for the country of 8.3% [5]. It was also demonstrated the presence of HCV II genotype D, found in 47%, even 53% determined genotype I. In European Russia (NW FD) dominates I virus genotype D (93%), whereas the virus genotype D defined II in rare cases – 7% [6]. Studies of recent years is set to determine the DNA of HBV (DNA virus) RNA and HDV (RNA virus D) for the diagnosis of viral hepatitis forecast D. Availability and degree of HDV RNA viral load of HBV DNA in the blood serum are signs of viremia, indicating both virus replication, that are associated clinically with significant inflammatory activity in the liver. The possibility of infection in patients with chronic hepatitis D other hepatitis viruses, as well as the possibility of more than 3 combined forms pointed out by many authors, and emphasize that HDV suppresses HBV replication and HCV (hepatitis C virus) [7.8].

The aim

The aim of research was to establish the clinical features, depending on the activity of the replication of hepatitis viruses B and D.

Materials and Methods

We studied 26 patients with viral hepatitis D with a determined activity replicative virus by PCR (polymerase chain reaction). Identified viral load (VL), hepatitis B virus and hepatitis C virus the D – qualitative (presence of the virus – (+) absent – (-) All patients were hospitalized in the infectious ward for patients with viral hepatitis YAKGB for the period 2015-2016.. The age of patients ranged from 28 to 78 years (median, ‘41). The patients performed the ELISA (enzyme-linked immunosorbent assay) study for the presence of markers of parenteral viral hepatitis (HBsAg, a-HCV and a-HDV), the standard general clinical biochemical blood tests. of the instrumental methods survey used ultrasonography (ultrasound), EGD (fibrogastroduodenoscopy) In order to determine the severity of the clinical course of the disease evaluated the following symptoms that characterize the development of cirrhosis of the liver:. flebektaziya (disruption of the normal functioning of the valves and veins of the esophagus), splenomegaly, portal hypertension, swelling of the upper and lower limbs, skin itching. Grading the severity of liver cirrhosis established by Child-Pugh (eng. Child-Pugh, Child-Turcotte, Child-Turcotte-Pugh, sometimes Child-Paquet) is designed to assess the severity of cirrhosis. The severity of liver cirrhosis is assessed on a point system, which are calculated from 5 or 6 parameters. In total there are three classes: A, B and C: Class A (Child A) – 5-6 points, Class B (Child B) – 7-9 points, Class C (Child C) – 10-15 points.

The statistical processing of the material carried out using SPSS STATISTICS 17.0 package (SPSS Inc.). Check the normality of the distribution of quantitative traits performed using the Kolmogorov criterion – Smirnov adjusted Lillieforsa criterion and Shapiro – Wilk. A comparison of independent groups by variables used Mann-Whitney, Kruskal-Wallis test and analysis of variance. A comparison of the qualitative characteristics was performed using the method chetyrehpolnyh table (contingency table) with calculation of χ2 test. Correlation analysis was used to identify and examine the relationship between quantitative traits by calculating the Pearson correlation coefficient and Spearman. The critical value of the significance level (p) is assumed to be 5%.

Results and discussion

To study the clinical manifestations of chronic hepatitis D analysis of clinical and laboratory parameters of disease in 26 patients with chronic viral hepatitis D. Among these men was 12 (46%), women – 14 (54%). Alarming situation prevailing most patients of working age. The proportion of young patients in total amounted to 69% (18-44 years of age under the new classification adopted by WHO). All patients diagnosed with chronic hepatitis D varying degrees of activity. ELISA method in these patients revealed HBsAg and total a-HDV. It should be noted that in these patients traditionally used diagnostic techniques revealed no active replication of hepatitis B virus markers such as HbeAg, a-HBcor IgM, hepatitis D – a-HDV IgM. Only by PCR was able to detect viruses of hepatitis B and D, which indicates the importance of molecular biological research methods followed by genotyping. So, of HBV DNA was detected in 11 (42.3%), RNA HDV – in 12 (46.1%) patients, and simultaneous replication of both hepatitis B and D (mixed DNA replication and RNA HBV + HDV +) was found in 6 (23 %) patients, mono virus replication D (HDV +) in the absence of replicating virus (HBV-DNA negative) – 4 patients. Three patients were absent in serum hepatitis viruses B and D (non-replicative variant or lower detectable viral load by PCR). Of the three identified options for chronic hepatitis D (in phases mixed mono replication and non-replicative phase) the first two differ rapidly progressive course with the end result in cirrhosis of the liver. Available factual material indicates the presence of different options for chronic hepatitis current D, depending on the activity of each of the replication of viruses.

A detailed examination of clinical and laboratory parameters of disease in 26 patients with chronic hepatitis D – in terms of cytolytic syndrome (aminotransferases – ALT, AST), viremia (HV DNA of HBV, the presence of HDV RNA) and clinical manifestations of the disease, chronic hepatitis D low activity was detected in 14 patients (53.5%), moderate to severe activity – the remaining 12 (46.5%) patients. Patients with chronic hepatitis D with moderate to severe active disease diagnosed cirrhosis. The diagnosis is justified by the presence of signs of portal hypertension patients – namely, not amenable to treatment of ascites, anasarca, peripheral edema and varicose veins in the lower third of the esophagus, identified during the gastroscopy. The most intense clinical manifestations of the disease in chronic hepatitis D (hemorrhagic, dyspeptic syndromes, telangiectasia and hepatomegaly) found exclusively in all patients. One-third – found manifestations of portal hypertension (37.3%). The most common clinical signs were forming cirrhosis due to chronic hepatitis D as liver fibrosis (62.4%), splenomegaly (42.4%), abdominal distension (41.5%), peripheral edema (22.6% ), itchy skin (13.5%). Consideration of the main clinical symptoms and syndromes are shown in Figure 1.

In 12 (46.1%) of patients on the severity of signs of portal hypertension, such as the dimensions of portal vein by ultrasound indications of esophageal varices on EGD indications, degree of fibrosis (fibroscan), peripheral edema proved cirrhotic stage of chronic hepatitis D. Graduation (class ) the severity of liver cirrhosis established by Child-Pugh (classes A, B, C). Half of the patients had Class A on Child Pugh (50%), 42% – Class B, 8% – Class C. This indicates that half of patients with cirrhosis of the liver proceeded relatively benign. Below, in Figures 2 and 3 shows the distribution of patients with chronic hepatitis D in the stage of liver cirrhosis by class Childe Social depending on the age of the patients.

Based on the data in individuals younger cirrhosis forms more slowly and more than half of patients at the time of examination was compensation stage (Class A – 58.8%). Patients in the elderly prevailed cirrhosis of class B (78.2%), in old age, the severity of cirrhosis corresponded to Class C.

The results of laboratory parameters, especially biochemical, examined patients confirmed the well-known thesis that the main feature of viral Hepatitis D is the development of mixed-hepatitis, ie, liver under the influence of two hepatotropic virus – HBV and HDV. Supporting the role of hepatitis B virus is undeniable, but there is every reason to believe that the leading role belongs to hepatitis D. In comparison with other etiological forms of viral hepatitis, hepatitis D is more severe, as due to the influence of two viruses.

In the study of laboratory data is noteworthy that hyperenzymemia reaches from minimal to high rates – from 85.0 to ALT 1715 U / L. with a high viral load in viral DNA (HBV) – 2648226,0 ± 953892,7 copies / ml in the presence of an RNA virus D (HDV +). Increased bilirubin was small and moderate (Table I).

At moderate and high activity of chronic hepatitis D were significantly higher than at low, the following laboratory parameters: ALT – 148.0 vs. 42,8 (K-W = 11,9; p = 0.0006); AST – 108.4 vs. 55.4 (p = 0.0006); GGT – 136.0 vs. 45.0 (p = 0.001). There is a clear dependence on the degree of increase of ALT in viral load: the higher the viral load, the higher the cytolysis of liver cells, confirming the direct effect of cytolytic viruses B and D – rho = 0,8; p = 0.0048 (all patients HDV RNA positive) (Figure 4).

The viral load in patients with highly active chronic hepatitis D was also higher – 3434238.0 against 420,980.5 (p = 0.01). And in males indicators of liver enzymes were higher than those of women: AST – 94.7 vs. 55.4 (p = 0.007); ALT – 149.7 vs. 29.4 (p = 0.0005); GGT – 127.0 vs. 58.0 (p = 0.008). Increased ALT indicates significant cytolysis hepatic cells. And mild hyperbilirubinemia was not so high as steadily increased over time. In most patients there is a decrease of the total protein content, namely fraction albumin in serum.

With an increase in viral load in the serum total bilirubin level and the number of platelets is significantly growing (rho = 0,6; p = 0,04 and rho = 0,6; p = 0,004, respectively). This shows that a high viral load causes these pathological symptoms as hyperbilirubinemia and thrombocytosis (Figure 5).

It is generally known that viral liver disease inhibit hematopoiesis. In patients we studied the presence of a-HDV HDV RNA and the average number of platelets and leukocytes were below – 242.0 vs. 112.0 (p = 0.02) and 6.9 versus 4.3 (p = 0.005), respectively. In patients with liver cirrhosis observed a similar picture: the mean platelet count was 95.5 versus 168.0 in patients without cirrhosis, leukocytes – 3.4 versus 6.7, respectively (p = 0.0006 and p = 0.0001). Other parameters were within normal average values.

Ultrasound examination revealed: enlarged liver, diffuse increase in echogenicity, cellular and depleted vascular pattern that shows a picture of chronic hepatitis, as well as the fact that there are changes that are typical lesions of the bile ducts.

Given the common path of infection, a significant proportion of patients detected the mixed infections with hepatitis viruses B, C and D. In our study, triple infection HBV + HDV + HCV was found in three patients, it was 11.5%. HbsAg, a-HDV, a-HCV, the study of PCR detected the hepatitis B virus (DNA of HBV, the viral load of 197,745 copies / ml), – One patient ELISA all serological markers of active replication of hepatitis viruses B, D, and C were identified hepatitis D (HDV RNA) and hepatitis C virus (HCV RNA, genotype 1b). The two other patients in the presence of serum hepatitis virus serological markers of HBV DNA was absent in the presence of HDV RNA and HCV RNA. Thus, in cases of mixed infection HBV + HDV + HCV in the interpretation of serological markers should be borne in mind that between viral agents exist competitive “struggle”, and depending on the replicative virus activity may be the prevalence of serological markers of a stronger virus.

All patients with chronic hepatitis D various options for gastritis were found during gastroduodenoscopy. In most cases met superficial gastritis (65.2%). Troubling relatively high frequency of erosive gastritis forms (21.7%), which may be due to microvascular abnormalities in the mucosa of the gastrointestinal tract caused by viral infection.

CONCLUSIONS

Chronic hepatitis D is a major health problem of the Republic of Sakha (Yakutia) as a result of the epidemiological spread, as well as severe and fulminant forms of active viral replication phase period. It found an increase in the intensity of the circulation of HDV-infection among patients with viral hepatitis B.

In the etiological structure of chronic viral hepatitis set the leading role of hepatitis D. Detected high for the Russian Federation the share of chronic hepatitis D in the etiological structure of all of chronic viral hepatitis, amounting to 40.0%. Analysis of the clinical manifestations of data, laboratory and instrumental data of 26 patients with chronic hepatitis D are hospitalized in the department of viral hepatitis YAGKB showed that more than half of the patients were men (54%) and young persons (69%). The most common clinical signs of chronic hepatitis D were liver fibrosis (62.4%), splenomegaly (42.4%) and bloating (41.5%). From the laboratory parameters were below normal average number of platelets above the norm – the median ALT and AST. Viral load averaged (2648226,0 ± 953892,7Me / ml). Moreover, there is a clear dependence on the degree of increase in transaminases in viral load, the higher the viral load the higher cytolysis of liver cells, confirming the direct effect of cytolytic viruses B and D. In more than half of patients had low activity of HGD, half – a relatively benign course of liver cirrhosis. In a small part of HGD patients noted weakness of the immune response (absence of well-HDV). In 13.6% of cases met mixed infection with hepatitis C. In men, there was a higher activity of HGD and the level of liver enzymes. Most patients with HGD or firmness of temporary disability. High viral load induced hyperbilirubinemia and thrombocytopenia. Liver enzymes are further enhanced with high activity. Thrombocytopenia and leucopenia occurred more frequently in the presence of cirrhosis. Thus, clearly there is a direct relationship between the activity of replicative virus HBV, HDV, and increased activity of aminotransferases. In general, biochemical picture of chronic hepatitis D in HDV replication phase and at a high viral load HBV (up to 10 Mill. Copies / ml) is characterized by cytolytic syndrome, disturbance of protein-synthetic liver function, as reflected in giperfermentemii and a violation in the coagulation system, followed by a decrease in the number of platelets. In the context of the dynamic observation of this group of patients showed that a high viral load of HBV and HDV replication activity of chronic hepatitis is characterized by progressive course, a bright clinical picture, cytolytic syndrome. Most patients with HGD or firmness of temporary disability. Clinical example proves once again that the simultaneous replication of both viruses HBV and HDV acute hepatitis in a short time becomes chronic with progressive, undulating course with a strong cytolytic syndrome and the formation of liver cirrhosis.

In the region of hepatitis D is registered in 40% of hospitalized patients with viral hepatitis B is more common among most young able-bodied men and occurs mainly in severe and with signs of portal hypertension resulting in fast disability. Thus, the main feature of chronic hepatitis D is its predominant tsirrogennost.

REFERENCES

1. P .Farsi. Delta hepatitis: an update. Hepatol., 2003. 39. 212-219.

2. D.Т. Abdurahmanov, V.F. Uchaikin, A.I. Smirnov. Chronic hepatitis B and D. – М.: GEOTAR Media, 2010. 249. Infectious diseases: a guide for physiciansю М.: GEOTAR Media, 2014. 479.

3. O.B. Nepesova. Chronic viral hepatitis and cirrhosis of the liver in Turkmenistan: clinical and epidemicological research: synopsis. Dis. … Dr. med. Sciences. М., 2002. 31.

4. S.I. Semjonov, R.G. Savvin, S.G. Nikitina, S.S. Maximova, S.S. Sleptsova. Parenteral viral hepatitis (В, С, D) in the Sakha Republic (Yakutia). Life Science Journal 2014. 11(8s). 454-458.

5. Semenov S.I. Features of chronic hepatitis D flow depending on the viral replicative activity: synopsis. dis. S-P., 2000. 23.

6. J.-C Wu., C.M. Chen, T.Z Chen. et al., Prevalence and type of precore hepatitis B virus mutants in hepatitis D virus superinfection and its clinical implication. J. Infect.Dis. 1996 Feb. 173(2). 457-9.

7. Y.F. Liaw, S.L. Tsai, I.S. Sheen et al., Clinical and virological course of chronic hepatitis B virus infection with hepatitis C and D virus markers. Am J. Gastroentorol. 1998. 93(3). 354-359.

The work was performed as part of the base project
№ 17.6344.2017

ADDRESS FOR CORRESPONDENCE

Sergey Semenov

Dzerzhinskogo, 53, apt. 219, 677009, Yakutsk, Russia

tel. 8-914-286-29-48.

e-mail: insemenov@yandex.ru

Received: 18.03.2017

Accepted: 02.07.2017

Figure 1. Frequency of clinical symptoms and syndromes in patients with chronic hepatitis D

Figure 2. The severity of liver cirrhosis in all patients by grade Childe-Pugh

Figure 3. Distribution by grade of severity of cirrhosis by Childe Social age groups

Figure 4. Indicators of ALT in patients with chronic hepatitis D with a viral load of HBV DNA and the positive RNA HDV (+)

Figure 5. Dependence of total bilirubin and platelet of viral load

Table I. Laboratory findings of patients with chronic hepatitis D (HDV+)

Laboratory findings

n

Average

Innaccuracy

Min

Max

Albumen

20

34,3

1,7

15,4

44,4

Points

12

6,8

0,5

5,0

11,0

The viral load (VL)

11

2648226,0

953892,7

197745,0

10000000,0

Hemoglobin

26

127,0

5,8

57,0

169,0

Iron

9

20,6

3,1

6,9

35,8

Potassium

7

4,0

0,1

3,6

4,4

Creatine

25

75,4

2,8

49,0

106,0

Urea

25

3,9

0,2

1,2

6,5

Sodium

7

139,8

0,6

138,0

142,0

Total protein

23

68,5

1,5

56,3

79,8

ESR

26

13,8

2,0

1,0

48,0

Platelets

25

136,4

14,0

56,0

350,0

Cholesterol

21

4,1

0,2

1,9

6,4

AP

23

123,8

9,3

67,0

219,0

Erythrocytes

26

4,1

0,1

1,9

5,6

n

Median

25 – 75 P

Min

Max

ALT

26

85,0

42,8 – 177,0

13,5

1715,0

AST

26

72,3

55,4 – 115,6

19,7

1189,0

Amylase

22

31,7

26,2 – 44,8

23,0

58,5

AFP

18

10,0

5,9 – 32,0

2,7

114,3

GGT

22

120,5

47,0 – 150,0

13,0

703,0

Glucose

25

4,5

4,1 – 4,6

3,5

8,4

White blood cells

26

4,5

2,8 – 6,5

1,6

308,0

Total bilirubin

26

16,7

11,5 – 23,7

3,8

94,0

REA

18

3,9

3,1 – 5,4

0,5

354,0